Employment Application
1475 S. Bascom Ave, Suite 111 Campbell, CA 95008
Phone 408.374.4956 Fax 408.374.4941
APPLICANT INFORMATION
Last Name
First
M.I.
Date
Other names by which you have been known
(for verification and reference checking purposes)
Street Address
Apartment/Unit #
City
State
ZIP
Home Phone
Cell Phone
E-mail Address
Date Available
Driver’s License Number/State
Position Applied for
Are you a citizen of the United States?
YES
NO
If no, are you authorized to work in the U.S.?
YES
NO
Are you under 18?
YES
NO
If you are under 18 and still in high school, you may be required to
provide a work permit upon hire.
Instructions for answering the following question regarding your criminal record history:
Do not respond “yes” concerning the following: arrests or detentions that did not result in conviction; referrals to, and participation in, any pretrial or post-trial diversion program;
marijuana-related convictions more than two years old; convictions for which the record has been judicially ordered sealed, expunged, or statutorily eradicated; convictions that occurred
more than ten (10) years ago; misdemeanor convictions for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed; and first
convictions for misdemeanors of drunkenness, simple assault, speeding, minor traffic violations, or disturbances of the peace or misdemeanor convictions where five (5) or more years have
elapsed between the application date and the date of conviction or completion of incarceration, whichever is later.
Have you ever been convicted of a crime?
YES
NO
If yes, what was (were) the offense(s)?
Date(s) and place(s) of conviction
A CONVICTION RECORD WILL NOT NECESSARLIY BE A BAR TO EMPLOYMENT. Factors such as age at the time of the offense, type of offense and relevance to the job for which you are
applying, seriousness and nature of the offense, and rehabilitation will be taken into account.
EDUCATION
High School
From
Address
To
Did you graduate?
College
From
NO
Degree
NO
Degree
NO
Degree
Address
To
Did you graduate?
Other
From
YES
YES
Address
To
Did you graduate?
YES
MILITARY SERVICE
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, explain
F_002, Rev 01
1
010915
PREVIOUS EMPLOYMENT
Company
Phone
Address
Supervisor
Job Title
Starting Salary
$
Ending Salary
$
Ending Salary
$
Ending Salary
$
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
$
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
$
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
REFERENCES
Please list at least one present or former manager.
Full Name
Relationship
E-mail
Address
Phone
Full Name
Relationship
E-mail
Address
Phone
Full Name
Relationship
E-mail
Address
Phone
READ AND CAREFULLY SIGN
I certify that the information contained in this application is correct to the best of my knowledge, and I understand that any misstatement or omission of information is grounds for ending
the hiring process or dismissal. I authorize verification of information provided on this application; and authorize the references listed above to give you all pertinent information concerning
my previous employment; and release all parties from all liability for any damage that may result from furnishing same to amulet. In consideration of my employment, I agree to conform
to the rules and regulation of Amulet Technologies. I further agree that either I or the Company may terminate my employment with or without cause and with or without prior notice, at
any time. Finally, I understand that no representative of the Company other than an Executive Officer has the authority to enter into any agreement for employment for any specified
period or time, or to otherwise alter the foregoing.
Signature
F_002, Rev 01
Date
2
010915